Le financement des soins infirmiers à domicile en Belgique - KCE

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48 Financing of Home Nursing KCE reports 122 5.2.1.7 Topic 7: Critique on lump sum financing The main critique on the current lump sum financing of nursing care is the lack of transparency. Especially the fact that only minimal criteria are used for registration of ‘pseudocodes’, is questioned. Because registration of ‘pseudocodes’ is often lacking, it is insufficiently known which nursing activities are performed for patients falling under the rules of lump sum payments. 5.2.1.8 Topic 8: Out-of-pocket payments for patients Some persons reflected on the patient’s out of pocket payments in home nursing. Two participants from self-employed nurses mentioned that many home nurses, employeenurses as well as self-employed nurses, did not charge for the co-payment part of the patient. They argued that it should be mandatory to ask patients to pay the personal contribution in order to hold them responsible, to take into account their personal contribution for the MAB (‘maximum billing’) and to avoid abuse. The patient in the role of manager of his budget for nursing care, such as the personal assistance budget (PAB) for handicapped persons in the Flemish community, was not considered as a good model, because many patients would experience difficulties to describe their need and choose appropriate nursing care and support. Key points • Stakeholders had a general critique on the lack of a global vision on health care organisation. They explained it partly as a result of the division of political competencies on health care in Belgium. • Stakeholders formulated detailed critiques on the fee-for service as it is currently applied via the nomenclature of home nursing: the incompleteness for financing different types of activities; the complexity resulting from application of different financing mechanisms and complex rules for financing of combined nursing activities; tariffs that insufficiently cover operational costs of workload and time, material cost, the absence vs. availability of family caregivers, time loss in urban traffic. • Many stakeholders also emphasized the (potential) merits of the current system. 5.2.2 Theme 2: Arguments for reforms 5.2.2.1 Topic 9: The extent of required change: radical or fundamental? Reflecting on the reform process to implement new financing mechanisms, two dominant opinions emerged: the good parts of the current system should be kept and incremental changes would be made for solving the critiques on the system. The latter participants agreed that the financing system should be a mixed system, partly fee-forservice and partly lump sum payments. 5.2.2.2 Topic 10: Principles of financing Practically all stakeholders agreed on their preference for a mixed system of fee-forservice payments for discrete nursing activities and lump sum payments for patient groups with higher case-mix levels. Some stakeholders expressed their preference to limit fee-for-service financing for simple and well defined care situations, and not to use it for complex and long term care. Many participants pleaded that financing should take outcome and quality of care into account. It was mentioned that the organisation and collaboration of nurses in nursing practices/services yield merits for quality of nursing care and that therefore the financing mechanisms should take into account the type of organisation of home nurses.
KCE Report 122 Financing of Home Nursing 49 A more flexible financing system of practices of home nurses and differentiation of functions should be implemented. In the context of this discussion, participants mentioned that quite a number of nurses combine a job in a hospital with some limited nursing activity as a self-employed home nurse. It was suggested that low activity levels and the limited availability of the part-time self-employed nurse could affect continuity and coordination of nursing activities. Several methods for differentiating payments according to the outcome/quality of care were mentioned: • Quality indicators and outcome parameters should be developed: e.g. patient satisfaction, HbA1c blood levels in diabetic patients. • The fees were mentioned as a very effective lever to promote the required nursing interventions: fee for unnecessary interventions should be low whereas fees for evidence based interventions should be high. • The use of an instrument (see further) would support the evaluation of quality of care. 5.2.2.3 Topic 11: Develop better control mechanisms All stakeholders agreed on the need for control procedures, especially with regard to nursing care delivery in the lump sum financing system and share the opinion that current control procedures were suboptimal. Home nurses requested more opportunities to develop self-control procedures using standardized and feasible instruments, without much administrative efforts. There was disagreement between the representatives from the authorities and the representatives from the sickness funds about which instance should be authorized to perform control of nursing care delivery at home. Home nurses and participants from sickness funds had different opinions on the existing procedures for sanctions. Anyway, participants from both, self-employed nurses and large organisations of employee nurses, questioned the fact that for several years, the authorities gave little or no feedback on the activity level of home nurses. Key points • All participants agreed on the principle that the financing system should be a mixed system consisting of fee-for-service payments for specific activities combined with lump sum/case-mix financing. • Arguments for reforms ranged from requesting a radical change into a complete new financing system to incremental adaptations of the current system, involving the introduction of pay for quality, working out better control mechanisms and clarity about sanctions. • It was proposed to evolve towards more communication and feedback between the financing agencies and the home nurses on range and content of activities. 5.2.3 Theme 3: Nursing related topics 5.2.3.1 Topic 12: General changes in home nursing Many participants focused on the shift towards the increasing health care delivery across settings (hospital – home nursing). This movement results in higher demands for complex care delivery, higher competencies and skills of general home nurses and more specialist nurses. Home nurses collaborating in a service for home nursing can easily ask advice from a specialist nurse of the service.
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Le financement des soins infirmiers à domicile en Belgique - KCE

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